MISSISSIPPI NASA SPACE GRANT 2017-2018
UNDERGRADUATE PRESERVICE TEACHER SCHOLARSHIP PROGRAM
MISSISSIPPI UNIVERSITY FOR WOMEN
I. APPLICANT INFORMATION
Name
Last / First / Middle
Address
Telephone / E-mail Address
Major(s) / Minor(s)
GPA / Expected Graduation Date
Demographics
Race: / Native American / Pacific Is. / African American / Hispanic / Caucasian / Other
Gender: / Male / Female
Person with disability: / Yes / No
II. INSTITUTION INFORMATION
Faculty Sponsor / Title
Institution / Department
Address
Telephone / E-mail Address
III. PROPOSED PRESERVICE TEACHER PLACEMENT
Approximate Starting Date: / Expected Completion Date:
Provide a short summary in the space provided below of the grades and subject matter you plan to teach as part of your preservice teaching. If possible include the schools of your placement.
IV. SPONSORED FUNDING
Use additional sheets if necessary. Note: You should list other internships for which you have applied.
Source / Amount / $
Source / Amount / $
V. STATEMENTS DESCRIBING YOUR ABILITIES AND CAREER GOALS.
VI. RECORD RELEASE AND TRACKING
By accepting this undergraduate preservice teaching scholarship program the awardee agrees to make available their faculty sponsor in-class teaching observations, reports submitted by the student’s supervising classroom teacher, and a student-submitted reflection on his or her experience as a teacher. Awardee will keep NASA informed about progress in their career and employment.
VII. CERTIFICATION
I certify that I am a citizen of the United States and am or will be a full-time student at MississippiUniversity for Women. I will comply with scholarship reporting/presentation requirements. I also certify that all information contained in this application is accurate.
Signature of Student / Date
I certify that I will serve as the student’s faculty sponsor and will supervise his/her internship.
Signature of MUW faculty sponsor / Date
PLEASE COMPLETE AND RETURN TO: DR. JOSHUA HANES (), 1100 COLLEGE STREET, MUW-100, COLUMBUS, MS 39701, AS SOON AS POSSIBLE.
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